Acute heart failure: Novel therapies on the horizon Serelaxin John R. Teerlink, MD FACC, FAHA, FESC, FRCP(UK) Professor of Medicine, University of California San Francisco Director, Heart Failure and Director, Echocardiography San Francisco VA Medical Center 23.May, 2015 Sevilla, Spain
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Acute heart failure: Novel therapies on the horizon
SerelaxinJohn R. Teerlink, MDFACC, FAHA, FESC, FRCP(UK)Professor of Medicine,
University of California San Francisco Director, Heart Failure and Director, Echocardiography
San Francisco VA Medical Center23.May, 2015Sevilla, Spain
• Financial Disclosure– J.R. Teerlink has received research grants
and/or consulting fees from Amgen, Cytokinetics, Janssen, Medtronic, Novartis, St. Jude, Takeda, and Trevena.
• Unlabeled/unapproved uses disclosure– I will be discussing investigational therapies
Acute heart failure: Novel therapies on the horizon
Lippicky RJ and Packer M. J Am Coll Cardiol 1993;22(4 Suppl A):179A-184A.
“To be of clinical value in the treatment of heart failure, a drug must permit patients either to feel better or to live longer, or both.”
• Onset of hemodynamic changes coincident with relaxin-2 elevation during 1st trimester of pregnancy; similar but smaller changes observed during the luteal phase of menstrual cycle
• Systemic and renal vasodilation occur in parallel, a unique facet of pregnancy• Systemic and renal hemodynamics recapitulated in rodent models using serelaxin
and similar effects observed in human studies
Maternal Hemodynamic Adaptations to Pregnancy
PARAMETER PREGNANCY
Systemic vascular resistance (dyn.s.cm2) 30%
Cardiac output (L/min) 20%
Global arterial compliance (mL/mm Hg) 30%
Renal vascular resistance (dyn.s.cm2) 20%
Renal blood flow (mL/min/1.73m2) 50-85%
Creatinine clearance (mL/min/1.73m2) 40-65%
Baylis, C. Am J Kid Dis 1999; Schrier, RW, et al. Am J Kid Dis 1987; Jeyabalan, A, et al. Adv Exp Med Biol 2007
Pre-RELAX-AHF: Main Conclusions• 234 patient, dose finding Phase II study• With optimal dose across multiple clinical outcome
domains was 30mcg/kg/d serelaxin had trends to:
Teerlink JR, et al. Lancet 2009;373:1429–1432.
- Improved dyspnea relief/ clinical course
- Decreased congestion- Reduced diuretic use- Less worsening heart
failure
- Shorter length of stay- Reduced days alive out
of hospital- ??? Improved
cardiovascular and all-cause survival
• No significant adverse events• No hypotension SAEs; Hypotension AEs similar to
placebo
Post-discharge evaluation period
Placebo (n=580)
Serelaxin 30 µg/kg/d (n=581)
0 6 12 24 48 h 5 d 14 d 60 d 180 d48 h study drug infusion period
Screening
Double-blind, randomized treatment and follow up period
Presentation <16 h
1,161 patients hospitalized for AHF
RELAX-AHF: Study design
Teerlink JR, et al. Lancet 2013; 381:29-39.
Standard HF therapyDuring study investigators free to use any concomitant medications incl. nitrates according to clinical judgment
Entry Criteria:• Dyspnea, Congestion
on CXR, Elevated BNP/ nt-ProBNP
• SBP >125 mmHg• eGFR 30-75 ml/min
1.73m2
• ≥40 mg IV furosemideExcluded:• Acute Coronary
Syndrome• High dose nitrates
Clinical events supersede symptoms at the time of their occurrenceClinical events supersede symptoms at the time of their occurrence
Visual Analog Scale Area Under the Curve:Dyspnea Clinical Composite
DeathDeathIn-hospital In-hospital
worsening worsening heart heart failurefailure
Change in Change in dyspnea scoredyspnea score
Visual Analog Scale Area Under Curve
Visual Analog Scale AUC With Worst Score Assignment
Moderate or markedworsening of symptoms atany planned assessment
Unresponsive or worsening heart failure requiring IV or mechanical interventions
Worsening heart failure requiring IV or mechanical
interventionsDeath Death
Visual Analog ScaleArea Under Curve
No dyspnea
Severe dyspnea
Numerical scoresover time
Worst score
5432100
5
10
15
20
25
30
35
AUC with placebo, 2308 ± 3082AUC with serelaxin, 2756 ± 2588p=0.0075
Cha
nge
from
bas
elin
e (m
m)
19.4% increase in AUC with serelaxin from baseline through day 5 (Mean difference of 448 mm-hr)
Days6
SerelaxinPlacebo
12 hrs
Teerlink JR, et al. Lancet 2013; 381:29-39.
1° Endpoint: Visual Analog Scale Area Under the Curve Composite
**HR 0.7 (0.51, 0.96); p=0.024
Cumulative proportion of worsening heart failureto Day 5 (%)
Worsening of Heart Failure
6 hr 12 hr Day 1 Day 2 Day 3 Day 4 Day 50
2
4
6
8
10
12
14
16
18Placebo (N=573)
Serelaxin (N=570)
Kaplan-Meier estimate D14for time to WHF (%)
11 3 16 4 31 10 44 17 5725 64 69 3736
Day 5 Day 140
2
4
6
8
10
12
14
16
18
573 570
(Numbers of subjects with WHF shown for each time point)
Worsening Heart Failure (WHF) was defined as worsening signs and/or symptoms of HF that required an intensification of IV therapy for heart failure or mechanical ventilatory or circulatory support.
n= 573 570
*p<0.001 through Day 5
*p value by Wilcoxon test; **p value by log rank test for Serelaxin vs. Placebo; HR estimate by Cox model
10
Teerlink JR, et al. Lancet 2013; 381:29-39.
Placebo(N=580)
Serelaxin(N=581)
Patients with WHF event included in the analysisof the 5-day primary endpoint 69 37
Patients who died or who experienced WHFleading to rehospitalization within 5 days 5 4
Patients with WHF within 5 days treated withIV positive inotropic drug or mechanical intervention 17 6
Patients with WHF within 5 days treated with new IV nitrates or IV nitroprusside 13 7
Patients with WHF within 5 days treated with reinitiation or doubling of daily dose of IV diuretic 14 7
Total 49 24
Worsening Heart Failure Events With More Intensive Rescue Intervention
P=0.003Teerlink JR, et al. ESC 2014 Clinical Trial Update Hotline
Primary Endpoint Sensitivity Analyses Based on Clinically Ranked Outcomes
PP valuevalueAnalysis of clinically ranked outcomes
All worsening heart failure events assignedsame rank 0.0190
Earlier worsening heart failure events assigned worse rank than later events* 0.0110
Recurrent worsening events assigned worse rank than single events 0.0150
Aggressive interventions ranked worse than IV vasodilators, ranked worse than IV diuretics 0.0183
Prespecified primary efficacy analysis 0.0075
Observed VAS scores and log rank test used; Modified from Finkelstein & Schoenfeld (1999) and Felker (2010)
Teerlink JR, et al. ESC 2014 Clinical Trial Update Hotline
Fewer Serelaxin Treated Patients Required IV Diuretics, Vasodilators, Inotropes and Mechanical Support
0
50
100
150
200
250
N=572 N=570IV d
iure
tics
use
(cum
ulat
ive
tota
l dos
e fro
m d
ay 1
-5 [m
g]) *p=0.006
Placebo Serelaxin
24%difference
Less use of IV diuretics in serelaxin group
0102030405060708090
100
N=580 N=581
Pat
ient
s tre
ated
with
IV v
asod
ilato
rs,
Inot
rope
s or
Mec
hani
cal S
uppo
rt (n
)
*p=0.017
Placebo Serelaxin
30%difference
16.4%
11.5%
Less use of IV Vasodilators, Inotropes and Mechanical Support in serelaxin group
P value by Wilcoxon rank sum test (death assigned longest length of stay plus 1 day)
HR (95%CI), P value• Pre-RELAX: 0.53 (0.22,1.30), p =
0.16• RELAX-AHF: 0.63 (CI 0.43, 0.93);
p=0.020 • Combined: 0.62 (0.43-0.88),
p=0.0076
Metra M, et al. J Am Coll Cardiol 2013;61:196-206.
Dyspnea Relief (VAS AUC Day 5) CV Death Through 180 Days
Metra M, et al. Eur Heart J 34:3128-36.
Cardiovascular mortality in Patients with HFpEF in RELAX-AHF
Filippatos G, et al. Eur Heart J 2014;35:1041-1050.
Hemodynamic Effects of Serelaxin in Patients with Acute Heart Failure
18v Study objective: To evaluate the hemodynamic effects of serelaxin in 71 patients
with AHF at a dose rate of 30 µg/kg/day
Swan-Ganz catheter inserted ≥ 1 h prior to randomization
4h post-infusion
30 d20 h study drug infusion
Placebo
Serelaxin 30 µg/kg/d
Double-blind, randomized treatment period
Serelaxin 100 µg/kg/d (n=37)
Serelaxin 250 µg/kg/d (n=49)
Patients hospitalized with AHF, mean PCWP ≥18 mmHg,SBP ≥115 mmHg, and estimated glomerular filtration rate ≥30 ml/min/1.73m2
Screening
≤48 hPresentation
Randomized 1:1
0 h 8 h 20 h 24 hSafety evaluation
Washout
Washout
Ponikowski P, et al. Eur Heart J 2014;35:431-441.
Hemodynamic Effects of Serelaxin in Patients with Acute Heart Failure
Ponikowski P, et al. Eur Heart J 2014;35:431-441.
*
**
** *
* * **
Renal Hemodynamic Effects of Serelaxin in Patients with Chronic Heart Failure
*Measured by plasma clearance of PAH and IOTH. CHF, chronic heart failure; GFR, glomerular filtration rate; IOTH, iothalamate; i.v., intravenous; PAH, para-amino-hippuric acid; RPF, renal plasma flow
v Study objectives: To assess the renal hemodynamic effects of 24 h i.v. infusion of serelaxin, as determined by RPF and GFR in CHF patients*
8 10 11 13 15 17 19 23 3 7 11 13 15Day -21 to -1 Day 1 Day 2
11:30
–3 –1 0 2 4 6 8 12 16 20 22 23 24 26 28 24.5
Time of day:
Wash-out
Wash-out
Furosemide infusion
IOTH/PAH
Urine collection
Screening
RandomizationPlacebo
Serelaxin 30 µg/kg/day i.v. infusion
0:10
0:30
20
Chronic HFNHHA II-IIILVEF ≤45%BNP ≥100 pg/mL
or NT-proBNP ≥400 pg/mL
Worsening sx within 3 mo
SBP≥110 mmHg
Voors AA, et al. Circ Heart Fail 2014;7:994-1002.
Renal Hemodynamic Effects of Serelaxin in Patients with Chronic Heart Failure
21
Time-weighted average change from baseline
Serelaxin(n = 28)
Placebo(n = 37)
Treatment difference†
(95% CI)p-value
0–24 h 1.31 (1.05) 1.13 (1.04) 1.16 (1.05, 1.28) 0.0042
8–24 h 1.29 (1.05) 1.14 (1.05) 1.13 (1.01, 1.27) 0.0386
24–28 h 1.35 (1.05) 1.16 (1.05) 1.16 (1.03, 1.30) 0.0115
CI, confidence interval; SE, standard errorData presented as least squares geometric mean ratio to baseline (standard error). †Ratio of least squares geometric mean ratios